Supervisor’s Report ofInjury or Illness
3. Employee’s name: / 4. Job title or position :
4. Date and time of event: / 5. Location or address where event occurred: / 5a. On employer property?
Yes No
6. Date of knowledge of the event: / 7. Name and title of person to whom the event was reported:
7. If the event was not reported immediately, why not?
8. Was employee given a claim form (DWC-1)?
Yes (date:______) No / 9. Did employee sign and return the claim form (DWC-1)?
Yes (date:______) No
10. Type of medical treatment required:
No treatment needed Medical treatment refused
Paramedics or EMT First aid
Emergency room Clinic
Hospitalized overnight / 11. Medical treatment provider:
(include name and address of facility)
Check if this is pre-designated provider
12. What was the employee doing at the time of the event? (Attach separate sheet if necessary)
______
______
______
13. Describe how the event occurred: (Attach separate sheet if necessary)
______
______
______
14. Type of Injury:
Bite, sting
Burn
Cancer
Cardiovascular, internal
Contusion, bruise
Cumulative trauma
Dermatitis, rash
Disease, blood-borne pathogen
Foreign body
Fracture
Hernia
Infection
Inflammation
Laceration
Mental disorder
Puncture
Strain/sprain
Other: ______/ 15. Cause of Injury:
Absorption, inhalation, ingestion
Animal, insect, plant
Assault, pursuit, criminal act
Burn, scald, temperature extreme
Caught in, between, under
Cut, puncture or scrape
Electrical current
Equipment, tools, machinery
Flying or falling object
Foreign body
Lifting
Object being lifted, handled, carried
Pushing, pulling, twisting, reaching
Repetitive motion, cumulative trauma
Slip, trip, fall
Struck by, against
Vehicle use, collision, upset
Other: ______/ 16. Mark affected area(s) on diagram:
17. Did employee lose time from work? No Yes – First day of lost time: ______
18. Has employee returned to work? No Yes – Date returned: ______
Full duty
Modified duty – Describe: ______
AttachmentsPage 1 of 2
Supervisor’s ReportEmployee’s Name: ______
19. Was the event witnessed? No Yes – List witnesses (Attach separate sheet if necessary)Name: ______Name: ______
Address: ______Address: ______
City, State, Zip: ______City, State, Zip: ______
Telephone: ______Telephone: ______
20. Check all conditions or actions that apply:
EQUIPMENT
Defective machine
Machine guards not in place
Machine guards missing – need to be installed
Improper tools
Defective tools
Improper protective equipment
Defective protective equipment
Inadequate protective equipment
Other: ______
ENVIRONMENT
Arrangement of equipment, work flow, tools
Poor housekeeping – cleanliness and organization
Inadequate lighting
Inadequate ventilation
Signs – inadequate signs or other forms of warning
Walking surface
Other: ______/ PROCEDURE
Unsafe procedures
Procedures missing
Procedures inadequate
Other: ______
TRAINING
Associate(s) lacks training
Associate(s) needs retraining
Other: ______
SUPERVISION
Procedures not enforced
Use of protective equipment not enforced
Use of machine guards not enforced
Other: ______
WORKER
Horseplay, unsafe behavior
Short cuts, carelessness
Distracted, inattentive
Other: ______
21. Describe the steps recommended or taken to prevent a recurrence:
______
______
______
22. List any employer property that was damaged and describe the damage:
______
______
23. Was the event caused by, or involve, a third party? No Yes – complete below:
Auto accident Rented or leased equipment Off-site activity Conference or seminar Construction area
Name and address of third party: ______
Description of involvement: ______
24. Other information:
Photographs taken? No Yes – by whom: ______
Police or fire called to event? No Yes – Agency: ______
Cal/OSHA contacted? No Yes – by whom: ______
Evidence preserved (contact Risk Management for guidance)? No Yes – by whom: ______
25. Comments: (Attach separate sheet if necessary)
______
______
______
Completed by (print name): ______Date: ______
Signature: ______Phone #: ______
AttachmentsPage 2 of 2
Rev.Julyl 2010